Healthcare Provider Details

I. General information

NPI: 1740194877
Provider Name (Legal Business Name): MANGO PEDIATRIC THERAPY, PLLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/28/2026
Last Update Date: 10/02/2026
Certification Date: 10/02/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

127 W HARGETT ST STE 301 PMB 254
RALEIGH NC
27601
US

IV. Provider business mailing address

127 W HARGETT ST STE 301 PMB 254
RALEIGH NC
27601-1351
US

V. Phone/Fax

Practice location:
  • Phone: 910-808-1830
  • Fax: 980-217-0306
Mailing address:
  • Phone: 910-808-1830
  • Fax: 980-217-0306

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QH0700X
TaxonomyHearing and Speech Clinic/Center
License Number
License Number StateNULL

VIII. Authorized Official

Name: ARIEL TRAVIS
Title or Position: OWNER
Credential: SLP-CCC
Phone: 919-307-9854